Transcription of Supplement A - New York State Department of Health
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Supplement A - New York State Department of Health
DOH - 5178A 8/15 (page 1 of 8)DOH -51 Supplement A ( Supplement to Access NY Health Care Application DOH-4220)This Supplement must be completed if anyone who is applying is: Age 65 or older Certified blind or certified disabled (of any age) Not certified disabled but chronically ill Institutionalized and applying for coverage of nursing home care. This includes care in a hospital that is equivalent to nursing home : If you are applying for the Medicare Savings Program (MSP) only, this Supplement does not need to be : Sections A through E must be completed and this Supplement must be signed. If you or anyone in your household is applying for coverage of nursing home care, you must also complete sections F through Applicant and Spouse Information Is a person named above: Chronically ill?
home and community-based waiver program Note: Some examples of home and community-based programs that provide waiver and other services are Traumatic Brain Injury Program and Nursing Home Transition and Diversion Program. You are institutionalized and applying for coverage of nursing home care. Documentation of your resources
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